River of Words Contest Entry Form

Note: If we cant read your handwriting, you cant win a prize and you wont get your Watershed Explorer Certificate. So, please print carefully and use a pen! Also, if we dont have your parents signature, you cant win a prize! Date: _______ Please check one: I am entering as an Individual____ , OR, as part of a Group/Class*____.

DO I CHECK THE INDIVIDUAL OR GROUP CATEGORY? ***This is important for receiving your certificate.***
Do not check the Individual entry category unless you are entering the contest all on your own (as a homeschooler, perhaps), not as part of a class, club or other group . If, like most entrants, you are entering through school or some other organization, you should check the Group entry category. If possible, all the entries from your group should be sent in the same envelope. You will each be individually eligible for a prize and will be individually acknowledged on your "Watershed Explorer" certificates, which will all be sent to your teacher or facilitator to hand out. Name:_____________________________ Email_______________________ Age:_____ Grade:____ Male: __Female: __ Title of Submission:_____________________________________________________ Art:____Poem:____ (Check one) If you submitted artwork, what medium did you use? (acrylic, pencil, pastel..?)________________________________ *Note: If you are entering as part of a group you MUST indicate whether you are entering through your school, scout troop, summer camp, park district, library, or other organization below. *NEW REQUIREMENT!* Teachers/Facilitators: You must include a typed list of the names of all entrants in your group, plus the total number of entrants! School or Organization_________________________________________________________________________________ School/Org Address____________________________________________ City___________________________________ State_______Zip/Postal Code_____________ Country:________________ School Phone _________________________ Teacher/Facilitator(s) First Name_______________________ Last _______________________________________ Parent or Guardian's Name________________________________ Signature ____________________________________ Home Address _______________________________________________City_____________________________________ State______ Zip/Postal Code____________ Country __________________ Home Phone_________________________
I hereby grant and assign to River of Words (ROW) the non-exclusive right and permission, in respect of the original writing, artwork or photos that I have submitted to River of Words, to use, re-use, publish, and re-publish, and otherwise reproduce, and display the same, individually or in conjunction with other original artwork, writing, photos, and video, in any and all media now or hereafter known throughout the world, for illustration, promotion, art, advertising, and trade, or any other purpose whatsoever; and to use my childs name to identify the author of the work in connection with my participation in the River of Words Program. I understand that any use of this submitted work will include my childs name as its creator. I hereby release and discharge River of Words from any and all claims and demands arising out of or in connection with the use of the original artwork, writing, photos, and video, including without limitations any and all claims for libel or invasion of privacy. In any of the winning categories, River of Words maintains the exclusive right to declare no winner and withhold prizes if no poem or artwork of merit is found. ROW assumes no responsibility for lost or damaged poetry or artwork. River of Words may sell, assign, license, or otherwise transfer all rights granted to it hereunder. This authorization and release shall also inure to the benefit of the successors, legal representatives, licensees, and assigns of River of Words. I have read the foregoing and fully understand the contents thereof. This release shall be binding upon me and my heirs, legal representatives, and assigns. I further release River of Words from any responsibility for injury incurred during the research or production of the original writing, artwork, photos and video.

I, _______________________________(signature), being the parent or guardian of the above-named minor, hereby consent to and join in the foregoing release and consent on behalf of said minor. Pledge of Originality: I declare and avow that the poem(s) or art I am submitting to the River of Words Contest is my own original work. Students signature_________________________________________________________________________________
River of Words, PO Box 4000-J, Berkeley, CA 94704 USA Tel: 510-548-POEM (7636) Fax: 510-548-2095 Email: info@riverofwords.org Website: www.riverofwords.org